Care Coordination
Li's new physician didn't mince words. At age 55, she had hypertension, obesity and pre-diabetes. To avoid serious illness and early death,
Li had to get serious about managing her conditions. Her doctor referred her to a Chronic Care Coordinator, and together, they began using the
Care Guide and making gradual changes to Li's self-care. The fact sheets and tools in her Care Guide explained how to safely exercise to lose
weight and how to monitor her blood pressure. And Li's dietician made sure cooking tips and nutritional guidelines were easily available in her
Care Guide. As time passed, Li's weight, blood pressure and cholesterol levels all started dropping, and her pre-diabetes disappeared. These early
successes encouraged her to keep going. Li credits the Care Guide and her "medical family" for supporting her through the hard work of making long-term
lifestyle changes.
Care Transition
When Arturo came home from rehab after a debilitating stroke, Carol wasn't sure how she would cope with his care. Using the Care Guide in tandem with
Arturo's medical team has made all the difference. The home-based primary care staff gave Carol advice she was able to apply gradually, such as
transitioning to durable medical equipment like a hospital bed and Hoyer Lift. Arturo's primary-care physician made sure all of Arturo's medications
were included in the Care Guide, so Carol could manage his meds and minimize side effects. Carol learned to safely assist an in-home care worker with
bed transfers, thanks to online training about home health care. And when Carol came down with the flu herself, she knew she could rely on respite care
to take over Arturo's care. Respite care was just one of the services she learned about in her Care Guide, thanks to her home-health nurse and social
worker. Being a family caregiver can be the toughest job in the world, but Carol credits the Care Guide with introducing her to a whole world of tools,
encouragement and support.
Personal Engagement
Diego was diagnosed with diabetes and high blood pressure. His restaurant job meant long, irregular hours - and access to a lot of unhealthy food. His
Care Guide helped him learn everything from medication management to healthier food choices to the importance of exercise and blood-sugar monitoring.
Slowly, Diego began making changes recommended in his Care Guide. During his work breaks, he walked around the block for exercise. He cooked at home
and brought his meals to work, instead of eating the restaurant's caloric, salty food. And he built a habit to test his blood sugar regularly, not every
now and then. Making the changes described in his Care Guide brought Diego's diabetes and blood pressure under control.